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    Exam Review

    1. A client is to receive enoxaparin 30 mg subcutaneously. Available is enoxaparin 40 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth).
      Correct Answer:0.8 mL
    2. The nurse is preparing to conduct a physical assessment. Which statement indicates a correct action by the nurse?
      A)
      Examine tender or painful areas first to help relieve the patient's anxiety.
      B)
      Organize the assessment to ensure that the patient does not change positions too often.
      C)
      Perform all examinations from the left side of the bed.
      D)
      Follow the same examination sequence, regardless of the patient's age or condition.
    3. Which of the following sets of vital signs represents normal values for a healthy adult at rest?
      A)
      Blood Pressure: 130/85 mmHg, Heart Rate: 88 bpm, Respiratory Rate: 22 breaths/min, Temperature: 100°F
      B)
      Blood Pressure: 110/70 mmHg, Heart Rate: 55 bpm, Respiratory Rate: 10 breaths/min, Temperature: 97°F
      C)
      Blood Pressure: 120/80 mmHg, Heart Rate: 72 bpm, Respiratory Rate: 16 breaths/min, Temperature: 98.6°F
      D)
      Blood Pressure: 140/90 mmHg, Heart Rate: 100 bpm, Respiratory Rate: 20 breaths/min, Temperature: 99.5°F
    4. A nurse is performing a physical assessment of a client's neck. Which assessment finding would the nurse consider expected?
      A)
      The jugular veins are visibly distended when the client is sitting upright
      B)
      The client reports tenderness when the thyroid gland is palpated
      C)
      The thyroid gland is visibly enlarged
      D)
      Full range of motion without pain or stiffness
    Page 1 of 17

    Exam Review

    1. A nurse is admitting a new client. Which of the followings steps of the nursing process is the nurse performing when formulating goals for a positive outcome?
      A)
      Assessment
      B)
      Implementation
      C)
      Planning
      D)
      Evaluation
    2. When performing an eye assessment using the PERRLA acronym, how do test for "A"?
      A)
      Ask the patient to follow your finger through the six cardinal fields of gaze.
      B)
      Move your finger slowly toward the patient's nose and observe the pupils constrict and the eyes converge.
      C)
      Shine a penlight into each eye and observe constriction of both pupils
      D)
      Ask the patient to focus on a distant object and then read a near vision card.
    3. A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse. The documentation states, "Blood pressure 102/58 mm Hg. client sitting up in a chair." Which of the following information should the nurse clarify?
      A)
      Unit of measurement
      B)
      Location of blood pressure cuff
      C)
      Position of the client
      D)
      Systolic blood pressure
    4. When conducting a health history prior to a nursing assessment, which of the following is the most important information to collect to ensure a comprehensive understanding of the patient's health status?
      A)
      The patient's recent travel destinations
      B)
      The patient's foods and dietary preferences
      C)
      The patient's preferred pharmacy and insurance information
      D)
      Current medications, including dosage and frequency
    Page 2 of 17

    Exam Review

    1. After assessing a client's peripheral pulses, which information should the nurse document in the medical record?
      A)
      Pulse strength and the client's blood pressure
      B)
      The rate, rhythm, strength, and pulse site
      C)
      The rate of each pulse
      D)
      Pulse location and the client's reported pain level
    2. A nurse plans to measure a client's temperature orally. Which action should the nurse take first to ensure an accurate measurement?
      A)
      Ask the client to breathe through their mouth during the temperature measurement.
      B)
      Place the thermometer directly under the client's tongue immediately after removing it from the probe cover.
      C)
      Ask the client if they have consumed hot or cold food, beverages, or smoked within the last 15 minutes.
      D)
      Instruct the client to keep their mouth slightly open during the measurement.
    3. When measuring the heart rate, which of the following is most important?
      A)
      Always use a doppler ultrasound to detect the heart rate
      B)
      Count the beats for 60 seconds if the rhythm is irregular
      C)
      Count the beats for 15 seconds and multiply by 4
      D)
      Count the beats for 30 seconds and multiply by 3
    4. A nurse is caring for a client who reports a decrease in central vision. The nurse should identify that this is a manifestation of which of the following visual impairments?
      A)
      Macular degeneration
      B)
      Cataracts
      C)
      Diabetic retinopathy
      D)
      Glaucoma
    Page 3 of 17

    Exam Review

    1. During an ear assessment, the nurse observes a bulging erythematous tympanic membrane with decreased mobility. What condition should the nurse suspect?
      A)
      Otitis externa
      B)
      Otitis media
      C)
      Tympanic membrane perforation
      D)
      Presbycusis
    2. During an oral assessment, the nurse observes white patches on the client's tongue and buccal mucosa that can be easily wiped away. What should the nurse suspect?
      A)
      Oral candidiasis (thrush)
      B)
      Aphthous ulcers
      C)
      Leukoplakia
      D)
      Streptococcus infection
    3. A nurse is conducting a health assessment on a newly admitted patient. The patient appears anxious and begins to speak in a rushed and disorganized manner. Which of the following responses by the nurse demonstrates therapeutic communication?
      A)
      "You need to calm down so I can complete this assessment properly."
      B)
      "Please stop talking so fast; I can't understand you."
      C)
      "I understand that you're nervous, but we need to hurry so we can finish the assessment."
      D)
      "I can see you're feeling anxious. Take your time, and we can go through this together."
    4. During a skin assessment, the nurse notes a blue discoloration of the client's lips and nail beds. How should the nurse interpret this finding?
      A)
      Age-related skin change
      B)
      Possible hypoxia
      C)
      Normal finding in darker skin tones
      D)
      Expected response to heat exposure
    Page 4 of 17

    Exam Review

    1. A nurse is caring for a client who has schizophrenia and is experiencing hallucinations. The provider prescribes chlorpromazine 50 mg IM every 4 hr as needed. Available is chlorpromazine injection 25 mg/mL. How many mL should the nurse administer per dose?
    2. A nurse is gathering data during a health assessment. Which of the following is an example of subjective data?
      A)
      The patient's blood pressure is 140/85 mmHg.
      B)
      The patient's respiratory rate is 18 breaths per minute.
      C)
      The patient reports feeling nausea.
    3. A nurse is assessing a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors?
      A)
      Decreased serum calcium
      B)
      Increased muscle mass
      C)
      Decreased circulation
      D)
      Increased collagen
    4. A nurse is assessing a client's peripheral perfusion by checking capillary refill. Which action should the nurse perform?
      A)
      Assess skin temperature after pressure
      B)
      Palpate the nail bed with two fingers
      C)
      Press on the patient's fingernail until it blanches, release, and observe how long it takes for color to return.
      D)
      Elevating the hand to observe color
    Page 5 of 17

    Exam Review

    1. A nurse is preparing to administer digoxin 5 mg PO to a client. The amount available is digoxin 0.5 mg/tablet. How many tablets should the nurse administer?
    2. A nurse is assessing the sacral area of a client who has been on bed rest for several days. The nurse notes intact skin with localized redness that does not blanch when pressure is applied. How should the nurse document this finding?"
      A)
      Deep tissue pressure injury
      B)
      Skin tear
      C)
      Stage 1 pressure injury
      D)
      Stage 2 pressure injury
    3. During a skin assessment of an adult client, which finding is considered expected?
      A)
      Multiple open lesions on the lower legs
      B)
      Skin appears cyanotic around the lips
      C)
      Skin is intact and evenly pigmented
      D)
      Skin turgor remains tented
    4. A nurse is preparing to inspect the tympanic membrane of an adult client. Which action demonstrates correct technique?
      A)
      Insert the otoscope deeply into the ear canal before visualization.
      B)
      Pull the auricle downward and backward before inserting the otoscope.
      C)
      Pull the auricle upward and backward before inserting the otoscope.
      D)
      Ask the client to tilt the head forward during the assessment.
    Page 6 of 17